Carbohydrate Counting at Different Levels: USA Management Guidelines Suha Khoury , RD

1. Carbohydrate Counting at Different Levels: USA Management GuidelinesSuhaKhoury, RD

2. To explain the carbohydrate counting approach and to demonstrate ways for applying it in diabetes nutrition management Purpose of Presentation 1

3. Defining carbohydrate counting approach and highlighting reasons behind popularity Explaining the goals and objectives for the levels of carbohydrate counting Presenting recommended teaching aids Discussing case studies Topics of Discussion 2

4. Definition Carbohydrate Counting is a meal planning approach based on the following ideas1 : Carbohydrates is the main nutrient affecting post-prandial glycemic response Total amount of carbohydrates is more important than source of carbohydrates Reasons behind popularity Effectiveness2 Flexibility3 Ease of implementation4 Definition and Reasons Behind Popularity 3 • 1. Using Carbohydrate Counting in Clinical Practice, JADA • 2,3,4. Practical Carbohydrate Counting, American Diabetes Association, 2001

5. 2.1. Level 1: Getting Started 2.2. Level 2: Moving On 2.3. Level 3: Using Insulin:Carbohydrate Ratios 2. The Three Levels of Carbohydrate Counting1 4 • 1. Carbohydrate Counting: Getting Started, The American Diabetes Association and The American Dietetic Association, 1995.

6. 2.1. Level 12.1.1. Goals • Goals of Level 1 of carbohydrate counting1,2,3 • Regulate blood glucose by balancing carbohydrate intake with the diabetes medication and physical activity • Achieve and maintain consistency of carbohydrate intake at meals and snacks at similar times each day • 1. Carbohydrate Counting: Getting Started, The American Diabetes Association and The American Dietetic Association, 1995. • 2. Practical Carbohydrate Counting, American Diabetes Association, 2001. • 3. Using Carbohydrate Counting in Clinical Practice, JADA, 1988, v98, n8 6

7. Objectives of Level 1 of carbohydrate counting1,2,3 Identify carbohydrate as the primary nutrient affecting blood glucose levels Determine what foods contain carbohydrates, protein, and fat Estimate accurately portion sizes Define 1 carbohydrate choice as 15 grams carbohydrate and as 1 bread, or 1 fruit, or 1 milk exchange Count carbohydrate in meal plan Determine time and carbohydrate goals for meals and snacks 2.1. Level 1 2.1.2. Objectives 7

8. Goals of Level 2 of carbohydrate counting1,2,3 Improve glycemic control through managing patterns of blood glucose as they relate to food intake, diabetes medication, and physical activity Increase flexibility in client’s lifestyle through advanced carbohydrate counting skills For type 1 diabetes, introduce the concept of insulin adjustment based on changes in usual carbohydrate intake 2.2. Level 22.2.1. Goals 8

9. Objectives of Level 2 of carbohydrate counting1,2,3 Apply concept of pattern management by Identifying patterns of blood glucose levels Determining relationships among food, diabetes medication, physical activity, and glucose levels Establishing guidelines for managing these variables Identify impact of protein and fat on glucose Count carbohydrates in choices or grams for Add 1 unit of short-acting or rapid-acting insulin for each additional 10-15 grams carbohydrates 2.2. Level 22.2.2. Objectives 9

10. 2.3. Level 32.3.1. Goals • Goals of Level 3 of carbohydrate counting1,2,3 • Improve BG control for people using intensive diabetes management by matching the amount of insulin with carbohydrate intake • To offer greater flexibility in food choices and portion sizes 10

11. 2.3.Level 32.3.2. Objectives • Objectives of Level 3 of carbohydrate counting1,2,3 • Explain insulin action; basal and bolus • Count carbohydrates using Carbohydrate Gram Method or Carbohydrate Choices Method • Calculate insulin:carbohydrate ratio and ISF • Adjust insulin for • Correct hypoglycemia and hyperglycemia 11

12. 3. Recommended Teaching Aids 3.1. The Exchange Lists 3.2. Carbohydrate Choices 3.3. Estimating Portion Sizes and Carbohydrate Choices 3.4. How Much Carbohydrate is Needed 3.5. Factors Influencing Glycemic Control 3.6. Carbohydrate Counting for Foods Containing Sugar Alcohols 3.7. The Actions of Insulin 3.8. Insulin:Carbohydrate Ratio 3.9. Calculating Carbohydrates in Recipes 3.10. Exchanges for Alcoholic Beverages 3.11. Treating Hypoglycemia 3.12. Exercise Guidelines 3.13. Guidelines for Illness 12

13. 3.1. The Exchange Lists1 13

14. 3.2. Carbohydrate Choices 14

15. 3.3. Estimating Portion Sizes1 and Carbohydrate Choices2 15

16. 3.4. How Much Carbohydrate is Needed1 16

17. 3.5. Factors Influencing Glycemic Control1,2 17

18. 3.6. Carbohydrate Counting for Foods Containing Sugar Alcohols (Polyols)1 18

19. 3.7. The Actions of Insulins1 19

20. 3.8.1. Method #1: Food dairy, insulin dose, and SMBG information 3.8.2. Method#2: The rule of 450 or 5001 3.8.3. Method#3: Using the insulin sensitivity factor (ISF) 3.8. Insulin:Carbohydrate Ratio

21. 3.8.1. Method #1 21

22. 3.8.2. Method #2 22

23. 3.8.3. Method #3 23

24. 3.9. Calculating Carbohydrates in Recipes1 24

25. 3.10. Exchanges for Alcoholic Beverages1 25

26. 3.12. Treating Hypoglycemia1 26

27. 3.13. Exercise Guidelines1 27

28. To replace 10 grams of carbohydrates To replace 15 grams of carbohydrates 3.14. Guidelines for Illness1 28

29. 4.1. Setting Carbohydrate Goals 4.2. Impact of Fiber 4.3. Applying Pattern Management 4.4. Applying Insulin:Carbohydrate Ratio 4.5. Determining Premeal Insulin Dose 4.6. Correcting Premeal Hypoglycemia 4.7. Correcting or Supplementing Insulin Dose 4. Case Studies 29

30. 4.1. Setting Carbohydrate Goals1 30

31. 4.2. Impact of Fiber1 31

32. 4.3. Applying Pattern Management1 32

33. 4.4. Applying Carbohydrate:Insulin Ratio1 33

34. 4.5. Correcting or Supplementing Insulin Dose1 34

35. 4.6. Determining Premeal Insulin Dose1 35

36. 4.7. Correcting Premeal Hypoglycemia1 36 1. Practical Carbohydrate Counting, American Diabetes Association, 2001